2011_0317CIiECiI� ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I_D- �
i l
LOCATION OF SERVICE= �' '. _ � ' _ � `. -' �" ,,''" / i ,�'.� i �._.
The backf7ow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� Rcduc. -d Pressure Principle a Pressure Va�-+•+�**+ Breaker
- -o.- Double Check Valve a Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located AL
Serial Number
The above is certified to be true.
Firm Name 31 � Certified Tester �' .. -" s . ,'`
Firm Address Cent Tester No. i r, - -, Date
Gauge #
Date Iast accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BRFaKFR
Double Check Valve Assembly
1st Cheri:
2nd Checl:
Relief Valve Air Inlet
Check Valve
Initial Test
DC- Closed
.Closed Tight -F,"�
Opened at Opened at
nsid
Tight -t7 �
Leaked o
psid nsid
_
RP -�psid
Leai:ed a
Did not Open �
Leaked D
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight D
Opened at Opened at
nsid
Repair
Tight Q
nsid nsid
RP std
The above is certified to be true.
Firm Name 31 � Certified Tester �' .. -" s . ,'`
Firm Address Cent Tester No. i r, - -, Date
Gauge #
Date Iast accuracy tested
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy